Session Eight (ADHD and Hyperactivity)

Question 1

Briefly describe the aetiology of ADHD?

Answer 1

• Affects males more than females (3:1)
• Common in children (about 5%)
• But can also persist into adulthood (2-4%)

Question 2

What are the 3 TYPES of symptoms you look for in a person with ADHD?

Answer 2

• Inattention
• Hyperactivity
• Impulsivity

Question 3

Give some examples of ADHD inattention symptoms? (9)

Answer 3

• Lack of attention to details
• Difficulty sustaining attention
• Does not listen when spoken to directly
• Trouble completing tasks
• Problems organising tasks and activities
• Avoids sustained mental effort
• Loses/misplaces things regularly
• Easily distracted
• Forgetful

Question 4

Give some examples of Hyperactivity symptoms in ADHD? (6)

Answer 4

• Fidgetiness (hand, feet, squirming in chair)
• Leaves set when not supposed to
• Restlessness or over active
• Difficulty in engaging in quiet leisure activities
• Always on the go
• Talks excessively

Question 5

Give some examples of Impulsivity symptoms in ADHD? (3)

Answer 5

• Blurts out answers before question has been completed
• Difficulty waiting in line or taking turns
• Interrupts or intrudes on others when they are working or busy

Question 6

What (vaguely) are the 3 traditional subtypes within ADHD?

Answer 6

• Hyperactive-Impulsive type
• Inattentive type
• Combined type

Question 7

What are the DSM criteria for diagnosing someone as having ADHD?

Answer 7

Symptom count:

• 6 for Inattention
• 6 for HI
• If 6 in each, patient is said to have combined type

Further diagnostic criteria:

• Symptoms maladaptive and inconsistent with developmental level
• Age of onset has to be before the age of 12
• Pervasiveness (symptoms must be present in two or more settings)
• Impairment (significant impairment of function or QoL in social/ academic/ occupational settings
• Symptoms are not better accounted for by another disorder

Question 8

Define ADHD.

Answer 8

ADHD = A persistent pattern of inattention and/or HI that interferes with functioning and development.

ADHD is NOT a manifestation of defiance, oppositional behaviour, hostility, failure to understand tasks or instructions

Question 9

What are some associated features of ADHD?

Answer 9

• Developmental delay in language, motor or social skills. Usually mild and non-specific but common co-occurrence.
• Emotional symptoms e.g. low frustration tolerance, irritability, mood lability.
• Educational problems, even in the absence of a specific learning difficulty, academic or work performance are usually impaired.
• Cognitive deficits e.g. attention, executive function, memory.

Question 10

What are the pros and cons of using the Impulsivity, Hyperactivity, Inattention model for ADHD diagnose?

Answer 10

Pros:

• These symptoms frequently co-occur and are distinct from other conditions
• This cluster is associated with significant impairment
• This method predicts treatment response

Con:
- All three phenomena (HII) are indistinguishable from the normal spectrum.

Question 11

How does ADHD present in adulthood?

Answer 11

Most commonly carried over symptom = Inattention (+ some Impulsivity)

• Disorganisation (difficulty planning ahead)
• Forgetfulness (misses appointments or loses things
• Procrastination (starts projects but doesn’t complete them)
• Time management problems (always late)
• Premature shifting of activities (start something, get distracted and move on)
• Impulsive decisions (especially around spending)
• Criminal offences (speeding, recreational drug use)
• Unstable jobs and relationships

Question 12

Why should adult mental health services be interested in ADHD?

Answer 12

• ADHD is associated with significant adult psychopathology
• ADHD symptoms may persists into adult life
• ADHD is a treatable disease

Question 13

Outline. the evidence for a genetic heritability of ADHD?

Answer 13

Faraone (2000):

• Family studies
• ADHD more common if you have a parent or sibling with the condition

Faraone (2005):

• Meta-analysis of twin studies
• Scores on ADHD symptom tests are highly heritable

McLoughlin (2011):

• Looked at shared genetic effect between the two domains of ADHD
• Inattention Hyperactivity-Impulsivity
• Correlation = 0.5-0.75

GCTA trial looked into SNP heritability for a number of conditions, found ADHD had higher SNP-heritability than BPD, Sz, MDD, ASDs.

Question 14

What neurochemical factors have been found to be at play in ADHD?

Answer 14

Cortese (2012):

• Dopaminergic and Adrenergic systems involved in ADHD
• Current drug therapies block DA and NA re-uptake and or promote release
• Studies show decreased availability of DA receptor isoforms and increased DAT binding vs controls.

Serotonin and Acetylcholine also implicated

Question 15

What has Demontis et al (2019), a massive GWAS study for ADHD, shown about the heritability of the condition?

Answer 15

• 20k cases vs 35k controls
• Identified 12 loci of significant clinical relevance.
• Heritability of ADHD due to these common variants = 22%

Question 16

What are Copy Number Variants (CNVs) and how do they relate to ADHD?

Answer 16

CNVs = Submicroscopic, rare chromosomal deletions and duplications.

Contribute to increased risks of ND disorders including autism, Sz, ADHD and intellectual disability. May go some way to explaining the genetic risk factors for these conditions.

Question 17

What Dietary risk factors have been studied in relation to ADHD? And how successful have these studies been?

Answer 17

Thapar (2013):

• Nutritional DEFICIENCIES (e.g. Zinc, Magnesium, Fatty acids)
• Nutritional SURPLUSES (e.g. Sugar, Artificial food colourings)
• Low, High IgG foods

All correlate, none proven link.

Question 18

What Psychosocial risk factors have been studied in relation to ADHD? And how successful have these studies been?

Answer 18

Thapar (2013):
- Family adversity and low income
- Conflict or hostility in the parent-child relationship
(both correlate, neither causal link established)

• Severe, early deprivation
  (high risk, likely causal risk factor)

Question 19

What Pre/Peri-Natal risk factors have been studied in relation to ADHD? And how successful have these studies been?

Answer 19

• Maternal smoking/ alcohol/ substance abuse
• Maternal stress
• Low birth weight

(all risk factors, no proven links)

Question 20

What Environmental Toxin risk factors have been studied in relation to ADHD? And how successful have these studies been?

Answer 20

• Organophosphates (e.g pesticides)
• Lead
• Polychlorinated biphenyls

(all risk factors, no proven links)

Question 21

How likely is low birth weight to be related to the development of ADHD?

Answer 21

Very, associated with ADHD even when you control for shared genetic and environmental factors.

Question 22

What are factors most strongly identified as possibly causing ADHD?

Answer 22

Genetic influence

Low birth weight, Premature birth, Severe early depravation

Question 23

What cognitive impairments are seen in children and adults with ADHD?

Answer 23

Franke (2018):

• Higher level function such as inhibitory control, working memory and planning
• Lower level (more automatic) functions such as vigilance, reward processing, timing
• POSSIBLY IQ (average 7-12 points lower, possible genetic link)

Executive control differences not as strong in adults.

Question 24

What is RVT?

Answer 24

Reaction Time Variability (inconsistencies in an individual’s speed of responding to a stimulus). Indicates EXECUTIVE FUNCTION

Generally higher in those with ADHD, indicating variations in how focused they are, however RTV can be boosted by providing the patient with incentives to focus.

RTV correlates with the patient’s baseline arousal levels. Essentially people with ADHD have lower general arousal making it difficult to focus on tasks.

Question 25

What are the two independent, genetically- inherited cognitive factors impaired in ADHD?

Answer 25

- Bottom-up influence from arousal structures that affects vigilance. - Executive control, which affects top-down control, inhibition, working memory.

Question 26

What EEG abnormalities are seen in individuals with ADHD?

Answer 26

- Atypical patterns of quantitative EEG frequency power - Mostly increased low frequency activity. - Higher delta and theta power in ADHD noted at the beginning of the session, higher beta at the end

Question 27

What are Event-Related Potentials in EEGs?

Answer 27

Scalp-recorded fluctuations in the brain's electrical activity (the electroencephalogram or EEG) elicited by a stimulus event such as the presentation of a word

Question 28

Are there any ERP abnormalities in children with ADHD?

Answer 28

Yes, relating to: - Attentional allocation - Inhibition - Response preparation - Error processing - Conflict monitoring

Question 29

What have fMRI studies on children with ADHD shown?

Answer 29

Dysfunctions in multiple large-scale brain networks, including: - Hypo-activation in the fronto-parietal executive control network AND ventral attention network - Hyper-activation in the default (DMN), ventral attention and somato-motor networks

Question 30

How does childhood ADHD translate into adulthood?

Answer 30

- 2/3rds will have symptoms causing some sort of impairment in adulthood - 50% partial remission - 15% retain full DSM criteria ADHD - Overall prevalence in adults is roughly 2.5-4.3%

Question 31

Which form of ADHD is more stable across the lifespan?

Answer 31

HI is more likely to disappear as they age. INN is more likely to be stable.

Question 32

What did Biederman 2012 show?

Answer 32

16 year prospective follow-up study of 260 individuals with ADHD. Showed: - Increased lifetime rates of anti-social, mood, anxiety and addictive disorders. - Impairment in psychosocial, educational and neuropsychological functioning related to ADHD and not co-morbidities.

Question 33

What is the Risk Model of ADHD?

Answer 33

ADHD is a risk factor for the development of co-occurring conditions, which explains the sky high rates of co-morbid Antisocial behaviour, Addiction, Depression, Anxiety....

Question 34

How common are co-morbidities in ADHD?

Answer 34

Extremely, almost all neurodevelopment conditions occur more commonly in those with ADHD. Examples include: - Dyslexia - Dyspraxia - Learning difficulties - Asperger's - Tics or Tourettes

Question 35

Are there differences in terms of co-morbidity between the two subtypes of ADHD (Inattention vs Hyperactivity-Impulsivity)?

Answer 35

Yes, Inattention patients seem to have unique issues with reading ability. HI patients have unique oppositional defiance issues.

Question 36

What happens to the cognitive deficiencies seen in ADHD once symptoms remit in adulthood?

Answer 36

Findings to date are limited and inconsistent, but evidence seems to suggest impairments in executive function do not distinguish ADHD remitters and persisters i.e it does persist. Cheung et al: - Vigilance measures of cognitive functions in ADHD patients were accurate markers of remission, improving alongside ADHD symptoms. - Executive control measures of inhibition and working memory were not sensitive to the ADHD persistence or remission. (these findings line up well with the two types of cognitive impairments identified as etiologically separate.)

Question 37

How does IQ relate to ADHD outcome going into adulthood?

Answer 37

Remitters appear to have higher IQ than persisters. Evidence: - IQ has successfully predicted ADHD symptoms and impairment at future follow up. - Longitudinal treatment studies also report positive associations between IQ and treatment response.

Question 38

How effective are the 3 cognitive impairments of ADHD (Preparation-vigilance, IQ, Executive Control) at predicting remission of symptoms as the patient ages?

Answer 38

PV = A marker of remission IQ = A potential moderator of outcome EC = Not associated with outcome. (this distinction supports the proposed theory that all these functions operate totally independently)

Question 39

Is there such a thing as adult-onset ADHD?

Answer 39

It is generally believed no, and that all cases diagnosed in adulthood actually just had sub-clinical or undiagnosed ADHD in childhood. HOWEVER, a recent study (2018) suggested it may be possible to develop ADHD symptoms following a brain injury.

Question 40

Outline the implications on adult life of an ADHD diagnosis?

Answer 40

- 2/3rds will have some sort of symptoms in adulthood - High rates of co-occurring conditions that may well carry over into adulthood - Specific cognitive impairments such as those affecting executive function may persist in spite of symptom remission - HI symptoms decline more with age than Inn symptoms.

Question 41

What are the general NICE guidelines on how to manage ADHD?

Answer 41

- Provide psycho-education as part of diagnosis. - Consider environmental modification ahead of medication - Stress the value of diet, nutrition and regular exercise - Ensure continuity of care into adulthood - Provide a comprehensive, holistic shared treatment plan that addresses psychological behavioural and occupational and educational needs.

Question 42

What are the NICE guidelines for pre-school children with suspected ADHD?

Answer 42

- Avoid drug treatment unless absolutely necessary - Parent-training education programmes are 1st line - If this is ineffective, try environmental modification - If this doesn't work send to specialist services - Only specialists can give ADHD meds to children below the age of 5

Question 43

What has NICE guideline reviews suggested about the use of parent-based interventions?

Answer 43

- Cost-effectiveness uncertain - Low evidence of effectiveness - Guideline Committee did not consider there was sufficient evidence to offer these interventions to all - However recognised their value in certain circumstances e.g. in conjunction with other treatments.

Question 44

What do NICE guidelines say about the management of school age ADHD?

Answer 44

1st Line = - Environmental modification - Information and psycho-education - Group-based parent training or education programmes 2nd Line = - Medication (only if ADHD symptoms still cause significant impairment)

Question 45

What do NICE guidelines for adults suggest?

Answer 45

- Environmental modification - Offer medication if symptoms and impairments still significant in at least one domain, after environmental modification - Offer psych treatment if they don't want meds, are struggling to adhere to meds, or if meds aren't sufficient

Question 46

What sort of environmental modifications have been shown to be effective in the management of ADHD?

Answer 46

- Seating arrangements - Lighting and noise - Reducing distractions - Shorter periods of focus with movement breaks - Reinforcing verbal requests with written instructions - Increasing physical activities - Matching tasks to an individuals abilities

Question 47

What benefits are typically seen in successful ADHD treatment?

Answer 47

- Less restlessness or fidgeting - Better sleep - Mood improves - Less concentration required to do basic tasks - Less boredom - Normal levels of effort required - Distractibility reduces - Planning and self-esteem improves

Question 48

What is the effect of ADHD on criminality?

Answer 48

Significant increase, someone with ADHD is nearly 10 times as likely to be convicted of a crime. But successful treatment can lead to a significant drop in risk of criminal behaviour.

Question 49

What effect can exercise have on ADHD symptoms?

Answer 49

Studies have show exercise can have a significant effect on: - ADHD symptoms - Anxiety amongst ADHD patients - Executive functioning - Social disorders Furthermore, a Swedish study showed that greater energy expenditure at age 16-17 predicted reduced ADHD symptoms at age 19-20 in identical twins, once confounding measures were accounted for.